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SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION SUBMITTED BY: Ms. HIBU YASE 1ST YEAR M.Sc. (N) MEDICAL – SURGICAL NURSING (2012 – 2014 BATCH) FORTIS INSTITUTE OF NURSING #20/5, YELACHENAHALLI, KANAKAPURA MAIN ROAD, BANGALORE-560078 SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1. NAME OF THE CANDIDATE AND Ms. HIBU YASE ADDRESS 1ST YEAR M. Sc. NURSING, FORTIS INSTITUTE Of NURSING, #20/5, YELACHENAHALLI, KANAKAPURA MAIN ROAD, BANGALORE-560078 2. NAME OF THE INSTITUTION FORTIS INSTITUTE OF NURSING, BANGALORE 3. 4. COURSE OF STUDY AND 1ST YEAR M.Sc. NURSING SUBJECT MEDICAL – SURGICAL NURSING DATE OF ADMISSION TO THE 15th JUNE 2012. COURSE 5. “A STUDY TO ASSESS THE TITLE OF THE TOPIC EFFECTIVENESS OF REPEATED STRUCTURED TEACHING PROGRAMME ON PROGRESSIVE IMPROVEMENT IN KNOWLEDGE OF NURSING STUDENTS REGARDING CARE OF PATIENT ON MECHANICAL VENTILATOR IN SELECTED NURSING COLLEGES, BANGALORE .” 1 6.0 BRIEF RESUME OF THE INTENDED WORK INTRODUCTION “We are what we repeatedly do. Excellence then is not art, but a habit” – Aristotle. Cell is the living structural and functional unit of life. Cells in human body continually use oxygen (O2) for the metabolic reactions that releases energy from the nutrient molecules and produce adenosine triphosphate (ATP). These reactions release carbon dioxide (CO2) as a byproduct. The respiratory system helps in gas exchange- intake of O2 and elimination of CO2 and cardiovascular system transports blood containing these gases between the lungs and body cells. Failure of either system disrupts homeostasis by causing rapid death of cells from oxygen starvation and builds up waste products. In addition to function of gas exchange, the respiratory system also helps in regulating pH, contains receptors for the sense of smell, filters inspired air, produces sounds and rids the body of some water and heat in exhaled air.1 When the respiratory system fails to function adequately, resulting in impaired gas exchange, the supportive device like mechanical ventilator is required. Mechanical ventilator is a positive pressure breathing device by which air and/or oxygen is forced into the lungs intermittently in a manner resembling normal breathing. Mechanical ventilation may be required for a variety of reasons, including the need to control the patient’s respiration during surgery or during treatment of severe head injury, to oxygenate the 2 blood when the patient’s respiratory efforts are inadequate and to provide rest to the respiratory muscles. Many patients placed on a ventilator can breathe spontaneously but the effort needed to do so may be exhausting.2 Galen was the first to describe ventilation of an animal though it was well over a thousand years later that positive pressure ventilation with a bellows device became an accepted technique for resuscitation of neardrowning victims. Negative pressure ventilation techniques, including negative pressure operating rooms were developed in the 19th and early 20th centuries for clinical use. The first negative pressure device to gain widespread use, the Drinker-Shaw "iron lung," was developed in 1928. Later refinements by Emerson during the 1931 polio epidemic resulted in a simplified and less expensive tank respirator which became the mainstay of treatment of paralytic poliomyelitis. In the early 1950s, positive pressure mechanical ventilation emerged following decades of developmental work in animal laboratories and growing clinical experience with cuffed endotracheal tubes in operating rooms. Clustering of patients with respiratory failure supported on positive pressure ventilators in Copenhagen in 1950s led the way to the development of modern day Intensive Care Units (ICUs).3 Today, there are numerous highly sophisticated and refined mechanical ventilators are available for clinical use.3 But prolonged period of mechanical ventilation is expensive for both the patient, in terms of the risk of complications such as Ventilator Associated Pneumonia (VAP) and to the health service due to the high cost of maintaining a patient in intensive care.4 Being on a mechanical ventilator is associated with risk of anxiety, 3 post-traumatic stress syndrome, nosocomial pneumonia, and premature mortality.5 Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. Effective collaboration requires open, extensive, and coordinated communication as well as shared team goals that will result in improved quality of care, patient safety, and discharge outcomes.6 Both doctors and nurses are responsible for making decisions about mechanical ventilation and weaning. 4 6.1 NEED FOR THE STUDY Caring for patients on mechanical ventilation has become an integral part of the nursing care in critical care or general medical-surgical units, extended care facilities and at home. The nurses, physicians and the respiratory therapist must possess good knowledge and understand each patient’s specific pulmonary need and work together to set realistic goals.3 The movement towards research and evidence-based practice in health care demands that the best available evidence is applied to practice. At the same time, the changes to role boundaries mean that nurses are assuming increased responsibility, especially in relation to decision making. While there is an increase in responsibility, there has been limited consideration about the application of best evidence and decision making by nurses in the context of their clinical work.7 Critical care nurses can identify subtle changes in a patient’s clinical status and initiate appropriate nursing interventions rapidly and effectively. The main components of nursing care for mechanically ventilated patients include the following: Performing frequent assessments including level of consciousness and vital signs. Verifying prescribed ventilator settings and appropriate alarm limits. Ensuring emergency equipments, such as manual resuscitation bags and oropharyngeal and nasopharyngeal airways are immediately available. Assessing the adequacy of cardiac output. 5 Evaluating the adequacy of oxygenation. Assessing the adequacy of ventilation. Monitoring the patient-ventilator interaction. Identify signs of flow dyssynchrony. Educating patients and their families (with the patient’s consent). Involving patients in the decision making regarding medical treatment and nursing care.8 A multi-center, cross-sectional, self-administered survey was conducted on nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands, and United Kingdom (UK), regarding decisional responsibility for mechanical ventilation and weaning. Findings indicate, according to nurse managers, that inter-professional collaboration was the predominant model for decisions about mechanical ventilation and weaning. The nurses generally had reasonable influence on decisions made. Inter-professional collaboration varied according to the type of decision with physicians more likely to select initial ventilator settings and nurses more involved in the ongoing titration of ventilation and determination of extubation readiness. ICU nurses maintain a near continuous presence at the bedside and therefore may be in a best position to titrate ventilator settings in response to changes in physiologic parameters.6 A four-year controlled, prospective, quasi-experimental study was conducted in MICU, surgical ICU (SICU), and coronary care unit (CCU) for one year before the intervention (period 1), one year after the intervention (period 2), and two follow-up years (period 3). The SICU and CCU served 6 as control ICUs. The finding shows that, before the intervention, there were 45 episodes of Ventilator associated pneumonia (VAP) (20.6 cases per 1000 ventilator-days) in the MICU, eleven (5.4 cases per 1000 ventilator-days) in the SICU, and nine (4.4 cases per 1000 ventilator-days) in the CCU. After the intervention, the rate of VAP in the MICU decreased by 59% (to 8.5 cases per 1000 ventilator-days) and remained stable in the SICU and CCU. The rate of VAP in the MICU continued to decrease in period 3 (to 4.2 cases per 1000 ventilator-days), and the rates in the SICU and CCU remained unchanged. Compared with period 1, the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 and by 8.9 days in period 3. They concluded that a focused education intervention resulted in sustained reductions in the incidence of VAP, duration of hospital stay, cost of antibiotic therapy, and cost of hospitalization.9 Although Mechanical ventilator is an essential life saving device which maintains ventilation and oxygenation, it can cause numerous complications. A sound knowledge regarding care of a patient on mechanical ventilator and patients’ clinical status enables clinicians to finetune ventilator settings to maximize the benefits of ventilator support while minimizing complications. Critical care nurses play a crucial role in improving the effectiveness of mechanical ventilation, preventing harm, and optimizing patient outcome.8 In developed countries, mechanical ventilators are no longer limited to the Intensive care unit but are now a part of long-term and home care support system.10 7 The researcher during her work experience observed that many nurses especially the fresh graduates have minimal knowledge about caring for a patient on mechanical ventilation. Therefore, in the light of the above facts and the experiences of the researcher, she felt that if we strengthen the knowledge base of student nurses regarding care of a patient on mechanical ventilator, by reinforced teaching and testing during student life, we can create more efficient nurses for the society. 8 6.2 REVIEW OF LITERATURE A review of literature on the research topic makes the researcher familiar with the existing studies and provides information which helps to focus on a particular problem, lays a foundation upon which to base new knowledge. It creates accurate picture of the information found on the subjects.11 A study was conducted to assess the effectiveness of the learning package, regarding care of a patient on mechanical ventilator on the knowledge of the staff nurses from the selected hospital, Mangalore. Finding shows that, the mean post-test knowledge score (x2=30.4) was higher than the pre-test knowledge score (x1=21.6). The mean post-test score ranged between 22 and 36 and that of pre-test ranged from 15-20 respectively. The mean percentage knowledge score of pre-test was maximum (68.8%) in “area of endotracheal suctioning” and minimum in the area of “working principle of ventilator” (36.6%) where as the mean percentage knowledge score of post-test was maximum in the area of “review of anatomy and physiology of respiratory system” (86.6%) and less in “working principles of ventilator” (65.0%). The mean difference between the post-test and pre-test knowledge was significant (t29=12.14) (t29=2.045 at 0.05 level). There is a significant association between knowledge of staff nurses regarding care of a patient on mechanical ventilator and working experience in intensive care unit (x2=5.24; p=0.05 level).12 A study was conducted at tertiary care hospital, in Karachi, Pakistan. Single group pre-test post-test design was used with a sample size of 40 nurses. The study investigated the impact of teaching module on nurses’ 9 knowledge to practice evidence based guidelines for the prevention of VAP. The knowledge of nurses, were assessed before, immediately after and four weeks after the intervention. The findings reveals that majority of the subjects were female (80%, 32/40), having qualified in diploma nursing and were fresher. Another significant feature of the study group is that 24 nurses did not have any experience of caring for critically ill patients. The study further shows that there was a difference in mean and standard deviation from baseline (7.8±2.9) to post-test:1 (10.8±2.0) and finally in post-test:2 (9.8±2.1). As compared to post-test:1, the scores slightly dropped in posttest:2 conducted at the interval of four week. Though there was a drop, the mean scores of post-test:2 were significantly higher than the mean scores of the pre-test.13 A study was conducted in the University of Illinois at Chicago (UIC), to evaluate the effectiveness of “simulation”, to determine the importance of adding simulation to the curriculum. The study design was a prospective, pre-test post-test study without a control group. Seven senior Acute Care Nurse Practice (ACNP) students participated in a one-time, 2.5 hour simulation on a patient with pneumonia and septic shock. The finding suggests that all students completed the pre and post written tests and the surveys. The mean correct responses on the written test increased after simulation (7.1±2.4 versus 10.3±1.5). Six of seven students improved their number of correct responses; one student had the same number of correct responses. Student’s confidence in their ability to manage a mechanically ventilated patient, and managing circulatory shock improved after simulation from generally “somewhat not confident” to “very confident”. Students 10 either “agreed” or “strongly agreed” that simulation enhanced critical thinking skills and evidence-based practice and should be mandatory part of ACNP education.14 A survey was designed in Acute Respiratory Distress Syndrome Network Teaching Hospital in Baltimore, to assess barriers related to clinicians’ perceived attitudes, knowledge and behaviors related to low tidal volume ventilation in acute respiratory distress syndrome among physicians, nurses, and respiratory therapists in intensive care units. There were 291 completed surveys, with a response rate of 84%. Barriers related to clinicians’ attitude, behavior, and intensive care unit organization were significantly higher among nurses and respiratory therapists’ v/s physicians. Knowledge related barriers also were significantly higher among nurses’ v/s physicians and respiratory therapists. Barriers were lower and knowledge test scores higher among fellows and attending physicians v/s residents. Similarly, barriers were lower and knowledge test scores higher among nurses with more than 10years of experience v/s less than 10years of experience. Important organizational and clinical barriers, including knowledge deficits, regarding low tidal volume were reported, particularly among nurses and resident physicians.15 A study was conducted in ICU of Royal Melbourne Hospital, Victoria, Australia, for three-month period, to describe the role of critical care nurses in making decisions about mechanical ventilation and weaning in ICU. A total of 3986 decisions on mechanical ventilation and weaning were identified, a median of six decisions per patient per day of mechanical ventilation. Among the 3986 decision episodes, 2790 (70%) occurred during 11 the weaning phase of ventilation. Among the recorded decisions, 2538 (64%) were made exclusively by nurses, 693 (17%) were made exclusively by medical staff, and 755 (19%) were made by collaboration. In the collaborative decisions, the patient’s bedside nurse discussed the situation with a medical colleague and nursing input was considered and used in the decision making process. Overall, in decisions made exclusively by nurses, results of arterial blood gas analysis and weaning were the primary indicators for changes in ventilator settings.16 A study was conducted to examine critical care nurses’ knowledge about the use of the ventilator bundle to prevent ventilator-associated pneumonia. A sample of 61 nurses working in coronary care and surgical intensive care were taken for the study. Changes in the nurses’ knowledge were evaluated by using a 10-item test, given both before and after the sessions. The finding reveals that after the education sessions, the nurses performed better on eight of the ten items tested. The areas of most significant improvement were elevation of the head of the bed, charting of the elevation of the head of the bed, oral care, checking of the nasogastric tube for residual volume, washing of hands before contact with patients, and limiting the wearing of rings and nail polish. Even after the education sessions, the nurses’ compliance with hand-washing recommendations before contact with patients was low, though statistically some improvement was apparent. Contraindications to elevation of the head of the bed did not appear to affect the nurses’ practices.17 12 6.3 STATEMENT OF PROBLEM A STUDY TO ASSESS THE EFFECTIVENESS OF REPEATED STRUCTURED IMPROVEMENT TEACHING IN PROGRAM KNOWLEDGE OF ON PROGRESSIVE NURSING STUDENTS REGARDING CARE OF PATIENT ON MECHANICAL VENTILATOR IN SELECTED NURSING COLLEGES, BANGALORE. 6.4 OBJECTIVES OF THE STUDY 1. To assess the existing knowledge of student nurses prior to structured teaching program on care of the patient on mechanical ventilator, by conducting pre-test. 2. To evaluate the effectiveness of structured teaching program as measured by progressive improvement in knowledge score on care of the patient on mechanical ventilator among nursing students by administering a knowledge questionnaire at four different time points at a gap of seven days interval. 3. To find an association between knowledge scores of student nurses on care of the patient on mechanical ventilator with selected demographic variables. 6.5 OPERATIONAL DEFINITIONS 6.5.1 ASSESS In this study it refers to, ‘measuring the knowledge of nursing student regarding care of the patient on mechanical ventilator’. 13 6.5.2 EFFECTIVENESS In this study it refers to, ‘significant gain in knowledge of the student nurses as determined by per-test and multiple post-test knowledge on care of a patient on mechanical ventilator’. 6.5.3 STRUCTURED TEACHING PROGRAM In this study it refers to, ‘the systematically developed and organized instructions, which is administered to the nursing students includes lecture and discussion, designed to provide information regarding care of a patient on mechanical ventilator’. 6.5.4 PROGRESSIVE IMPROVEMENT In this study it refers to, ‘continuous improvement in knowledge due to continuous and repeated reinforcement by using a structured teaching programme. 6.5.5 KNOWLEDGE In this study it refers to, ‘the correct level of response from nursing students regarding care of a patient on mechanical ventilator, which will be elicited through structured questionnaire’. 6.5.6 CARE OF PATIENT In this study it refers to, ‘nursing care of a patient receiving mechanical ventilation’. 6.5.7 MECHANICAL VENTILATOR In this study it refers to, ‘a life saving device that can support the ventilatory function of the respiratory system and improves oxygenation through application of high oxygen content gas and positive pressure’. 14 6.5.8 NURSING STUDENT In this study it refers to, ‘student who is studying in 3rd year B.Sc. nursing in selected college of nursing in Bangalore’. 6.6 ASSUMPTIONS 1. Students may have inadequate knowledge on care of a patient on mechanical ventilation. 2. Structured teaching program on care of a patient on mechanical ventilator may help in improving their knowledge and thereby reduce complications. 6.7 HYPOTHESIS H0.1: There is no significant difference between the pre-test knowledge scores and post-test knowledge scores of nursing students exposed to repeated Structured Teaching Program. H1.1: There is significant difference between the pre-test knowledge scores and post-test knowledge scores of nursing students exposed to repeated Structured Teaching Program. H0.2: There is no significant association between the multiple teaching and progressive improvement in knowledge score of nursing students exposed to repeated Structured Teaching Program. H1.2: There is a significant association between the multiple teaching and progressive improvement in knowledge score of nursing students exposed to repeated Structured Teaching Program. 15 H0.3: There is no significant association between the levels of knowledge scores of nursing students and selected demographic variable. H1.3: There is a significant association between the levels of knowledge scores of nursing students and selected demographic variable. 6.8 VARIABLES IN STUDY Independent variables: In the present study, independent variable is the structured teaching program on care of patient on mechanical ventilator. Dependent variables: In the present study, dependent variable is the progressive improvement in the knowledge score of the nursing students regarding care of patient on mechanical ventilator. Demographic variables: In the present study, demographic variables are age, gender, religion, family income, type of family, place of living and source of information. 7.0 MATERIALS AND METHODS 7.1.1 Source of data : Nursing students of selected college of nursing, Bangalore. 7.1.2 Research approach 7.1.3 Research design : An evaluative research approach. : A quasi-experimental time series design with one group pre-test & multiple post-test without control group. 16 7.1.4 Research setting : The study will be conducted in selected college of nursing, Bangalore. 7.1.5 Target Population : Population of the study is the nursing students studying in selected college of nursing, Bangalore. 7.1.6 Sample Students studying in 3rd year B.Sc. : nursing in selected college of nursing, Bangalore. 7.1.7 Sampling technique : Non probability purposive sampling technique will be adopted to select the subject. 7.1.8 Sample size : 60 nursing students in selected college of nursing, Bangalore who fulfills the inclusion criteria. 7.1.9 Sampling criteria Inclusion criteria : Third year B.Sc. nursing students who are willing to participate in the study. Exclusion criteria : Third year B.Sc. nursing students who are absent during the period of data collection. : Nursing students who have already participated in study related to knowledge on ventilator. 17 7.2.1 TOOL FOR DATA COLLECTION Data will be collected using structured questionnaire. Data collection tool contain items on the following aspects: Part1: Consists of demographic variables such as age, gender, religion, family income, type of family, place of living and source of information. Part2: Structured knowledge questionnaire regarding care of a patient on mechanical ventilator. 7.2.2 METHOD OF DATA COLLECTION The data required for the study will be collected by using a structured knowledge questionnaire. A sample size of 60 nursing students will be selected by non probability purposive sampling technique. Written consent will be taken from each student and pre-test will be administered, followed by structured teaching program. First post-test will be administered after seven days. Total of four structured teaching program will be administered at the interval of seven days and after each of the teaching program a posttest will be administered. 7.2.3 METHOD OF DATA ANALYSIS The investigator will analyze the data obtained by using descriptive and inferential statistics. The plan of data analysis as follows: Descriptive statistics Data will be analyzed using Percentage, Mean, Mean %, Median, Standard deviation and results will be represented using tabular and graphical method. 18 Inferential statistics Repeated measures of Analysis of Variance is used for testing the difference between Mean pre-test and post-test knowledge scores. Chi square [χ²] for measuring association between knowledge level and selected demographic variables. The result will be statistically significant whenever P≤0.05 level of significance. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON OTHER HUMAN OR ANIMAL? Yes, the knowledge of 3rd year B.Sc. nursing student will be assessed by using a structured questionnaire. 7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM THE INSTITUTION? a. The ethical clearance is obtained from the research committee of Fortis Institute of Nursing. b. Written permission will be obtained from the concerned authorities of selected college of nursing. c. Informed consent will be obtained from the samples who are involved in the study before collecting the data. 19 8.0 LIST OF REFERENCE: 1. Tortora Gerard J, Derrickson Bryan. Principles of anatomy and physiology, 11th ed. United State of America (USA): John Wiley &Sons, Inc. publication, 2006; p.847. 2. Smeltzer Suzanne C, Bare Brenda G. Brunner and Suddarth’s textbook of medical surgical nursing 10th ed. Philadelphia: Lippincott Williams and Wilkins; P.613. 3. Ednan k Bajwa. Mechanical Ventilation. American Thoracic Society 2009 Aug [cited 2012 Setp 6]. Available from: URL:http://www.thoracic.org/clinical/best-of-the-web/pages/criticalcare/mechanical-ventilation.php 4. Taylor Fran. A comparative study examining the decision-making process of medical and nursing staff in weaning patient from mechanical ventilation. Intensive Crit Care Nurses 2006 Oct [cited 2012 Nov 5]; 22(5): 253-63. Available from: URL:http://www.ncbi.nlm.nih.gov/pubmed 5. Eckerbald J, Eriksson H, Karner A, Edell-gustafsson. Nurses' conception of facilitative strategies of weaning patients from mechanical ventilation- aphenomenographic study. Intensive Crit Care Nurses 2009 Aug [cited 2012 Oct 10]; 25(5):225-32. Available from: URL:http://www.ncbi.nlm.nih.gov/pubmed 6. Rose Louise, Blackwood Bronagh, Egerod Ingrid, S Haugdahl Heges, Jose Hofhuis, Michael Isfort, et al. Decisional responsibility for mechanical ventilator and weaning: An international survey. Critical care 2011 Dec [cited 2012 Sept 4]; 15(6):295. URL:http://ccforum.com/content/15/6/R295 20 Available from: 7. Hancock HC, Easen PR. The decision-making processes of nurses when extubating patients following cardiac surgery: an ethnographic study. Int J Nurs Stud 2006 Aug [cited 2012 Oct 20]; 43(6): 693-705. Available from: URL:http://www.ncbi.nlm.nih.gov/pubmed 8. Jin Xiong Lian. Basics of mechanical ventilation. Men In Nursing 2008 Dec [cited 2012 Oct 22]; 3(6): 10-16. Available from: URL:http://www.nursingcenter.com/prodev/ce article.asp?tid=830701 9. Apisarnthanark A, Uavporn P, KanokPorn T, Chanart Y, David K, Jeanne E, et al. Effective of an educational program to reduce ventilator-associated pneumonia in a tertiary care centre in Thailand: A 4-year study. Oxford Journal of Nursing 2007 May [2012 Aug 29]; 45(6): 704-11. Available from: URL:http://cid.oxfordjournals.org/content/45/6/704.full 10. Lewis Sharon L, Heitkemper Margaret Melean, Dirksen Shannon Ruff, O’Brien Patricia Graber, Bucher Linda, Mani Mrinaline. Lewis’s medical-surgical nursing assessment and management of clinical problems. 1st ed. Delhi: Reed Elsevier India (Pvt) Ltd; 2011. P.1717. 11. Polit Denise F, Beck Cheryl Tatano. Nursing research generating and assessing evidence for nursing practice. 8th ed. New Delhi: Wolters Kulwar (India) Pvt Ltd; 2008. P.105. 12. Shubhashini s. Effectiveness of learning package regarding care of a patient on mechanical ventilator to the staff nurses of selected of hospital in Mangalore. Available from: URL:http://119.82.96.198:8080/jspui/bitstream/12345789/4268/1/shu bhasini%20s.pdf 21 13. Salima Moez Meherali, Yasmin Parpio, Tazeen S Ali, Fawad Javed. Nurses’ knowledge of evidence-based guidelines for prevention of ventilator- associated pneumonia in critical care areas: A pre and Posttest design. J Ayub Med Coll. 2011 [cited 2012 Oct 23] 23(1). Available from: URL:http://www.ayubmed.edu.pk/JAMC/23- 1/Salima.pdf 14. Thomas C Corbridge, Susan J. Corbridge, Rich Mc Laughlin, Rozanna Templin, Jenny Tiffin, Leonard Wade. Acute Care adviser: Using simulation to enhance knowledge and confidence. Available from: The Nurse Practitioner: The American Journal of Primary Health care: 2008 June; 33(6):12,13. 15. Dennison CR, Mendez-Tellez PA, Wang W, Pronoyost PJ, Needham DM. Barriers to low tidal volume ventilation in acute respiratory distress syndrome: Survey development, validation and results. Crit Care Med 2007 Dec [cited 2012 Oct 23]; 35(12): 2747-54. Available from: URL:http://www.ncbi.nlm.nih.gov/pubmed 16. Louise Rose, S B Lawrence. Decisions made by critical care nurses during mechanical ventilation and weaning in an Australian intensive care unit. Critical Care Management 2006 Feb [cited 2012Aug 28]: 445,446. Available from: URL:http://www.aacn.org/WD/CETests/Media/A071605.pdf 17. Tolentino-delos Reyes AF, Ruppert SD, Shiao SY. Evidence-based practice: use of the ventilator-associated pneumonia. Am J Crit Care 2007 Jan [cited 2012 Sept7]; 16(1): 20-7. Available from: URL:http://www.ncbi.nlm.nih.gov/pubmed 22 9.0 Ms. Hibu Yase SIGNATURE OF THE CANDIDATE 10.0 REMARKS OF THE GUIDE Study is feasible. Sample size, sample technique, method of data collection and analysis is appropriate for study design. 11.0 NAME AND DESIGNATION OF Prof. Shridhar K.V. 11.1 THE GUIDE Principal 11.2 SIGNATURE Prof. Shridhar K.V. 11.3 CO-GUIDE Mr. Prabhuswamy A.C. Associate Professor 11.4 SIGNATURE Mr. Prabhuswamy A.C. 11.5 HEAD OF THE DEPARTMENT Prof. Shridhar K.V. 11.6 SIGNATURE Prof. Shridhar K.V. Principal Study design is strong. The outcome of the study contributes to the knowledge base of nursing. 12.0 12.1 REMARKS OF THE PRINCIPAL Prof. Shridhar K.V. 12.2 SIGNATURE 23